The total number of people officially waiting for treatment to begin is likely to be around 5.38 million compared to the current 4.08 million.

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1 RTT waiting time forecasts August 2018 Overview This paper summarises how referral-to-treatment waiting time figures have changed over the past five years and estimates likely figures by March 2024, i.e. the end of the five-year funding period that was announced by the Prime Minister on 18 June It assumes that waiting times continue along their current trajectories. Total waiting The data suggests that by the end of the current funding period, March 2024: The total number of people officially waiting for treatment to begin is likely to be around 5.38 million compared to the current 4.08 million. When taking missing data into account due to trusts that do not report their waiting times, the total number of people waiting is likely to be around 5.57 million. The number of people waiting for longer than 18 weeks is likely to rise to around 906,325. The percentage of patients beginning treatment within 18 weeks is likely to decrease from the current 88.1% to around 83.1%. The recent surge in people waiting over one year is likely to continue because of the growing backlog of people waiting ever closer to 12 months. Long-term waiting The paper also examines changes in the number of people waiting over 52 weeks, and the pressures that are likely to make it very challenging to eliminate waiting beyond than one year. There are currently 3,101 people who have been waiting for over one year for their treatment to begin. This number has surged over the past six months and is double that reported six months earlier in November An analysis of the number of people waiting over six and nine months shows that the pressure on long-term waiting has already sizeably increased. The number of people waiting for longer than nine months is 70% higher than 12 months ago. Further, there are over 211,000 people waiting over six months for treatment, which is close to 70,000 more people than were waiting this long a year ago. This suggests the surge in people waiting over one year is likely to continue because of the growing backlog of people waiting ever closer to 12 months. 1

2 The total number of people waiting for treatment to begin Current situation Over the course of the past three years, the number of people on the incomplete RTT pathway has risen from just under 3.2 million in June 2015 to a new all-time-high of 4,082,432 in May 2018 (the latest month for which figures are available). This is shown below by the thick purple line below. 4,500,000 4,300,000 4,100,000 3,900,000 3,700,000 3,500,000 3,300,000 3,100,000 2,900,000 2,700,000 2,500,000 Total no. of people waiting Since June 2018, NHS England has published its estimates for the number of people waiting at NHS trusts that do not publish their waiting times. These estimated figures are shown above by the dotted line. This reveals that the total estimated number of people waiting in May 2018 has reached 4,269,917. 2

3 Jun-13 Nov-13 Apr-14 Sep-14 Feb-15 Jul-15 Dec-15 May-16 Oct-16 Mar-17 Aug-17 Jan-18 Jun-18 Nov-18 Apr-19 Sep-19 Feb-20 Jul-20 Dec-20 May-21 Oct-21 Mar-22 Aug-22 Jan-23 Jun-23 Nov-23 Forecast number of people waiting If growth continues along the same trajectories that we have seen over the past three to five years, the official total number of people waiting is likely to be between 5,354,784 and 5,404,011, i.e. around 5.38 million by March This compares to 4,082,432 in May 2018 (the latest month for which figures are available). 6,000,000 The number of people waiting for treatment to begin 5,500,000 5,000,000 4,500,000 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 Source: NHS England 2 The above estimate does not consider the number of people missing from waiting list figures. NHS England estimates that the number of people missing from the data is currently 187,485. It is difficult to estimate the future scale of missing data because it is due to a small and changing set of providers that for various reasons have not reported their waiting time figures. However, NHS England s estimates of people missing from the waiting data averages at 174,207 over the past five years, and 202,503 over the past three years. Today s missing figure is therefore close to the mid-point of these two longer-term averages and it is a reasonable assumption that we should add a similar figure to the forecast figure. It follows that we can expect that the actual total number of people waiting by the end of the current funding period (March 2024) is likely to be around 5.57 million. This compares with NHS England s estimate of 4,269,917 total people waiting in May 2018 (latest available figures). 2 Source: NHS England Consultant-led Referral to Treatment Waiting Times, incomplete pathway data Key for all forecast graphs: Orange: published figures Blue: forecast based on 5-year historic trajectory Grey: forecast based on 3-year historic trajectory 3

4 Jun-13 Nov-13 Apr-14 Sep-14 Feb-15 Jul-15 Dec-15 May-16 Oct-16 Mar-17 Aug-17 Jan-18 Jun-18 Nov-18 Apr-19 Sep-19 Feb-20 Jul-20 Dec-20 May-21 Oct-21 Mar-22 Aug-22 Jan-23 Jun-23 Nov-23 The number of people waiting for longer than 18 weeks The current official number of people waiting for longer than 18 weeks is 485,201. On current trajectories this is likely to rise to between 830,577 and 982,073, so around 906,325 by March ,000, , , , , , , , , ,000 0 No. > 18 weeks 4

5 Jun-13 Nov-13 Apr-14 Sep-14 Feb-15 Jul-15 Dec-15 May-16 Oct-16 Mar-17 Aug-17 Jan-18 Jun-18 Nov-18 Apr-19 Sep-19 Feb-20 Jul-20 Dec-20 May-21 Oct-21 Mar-22 Aug-22 Jan-23 Jun-23 Nov-23 Percentage of patients beginning treatment within 18 weeks We expect a decrease from the current 88.1% to somewhere between 81.7% and 84.6%, so most likely around 83.1%. It is worth noting that the waiting time standard is that 92% of patients should begin their treatment within 18 weeks. If the 3-year historic trajectory continues, we can therefore expect double the number of people to be waiting longer than 18 weeks as guaranteed by the waiting time standard. 1 % within 18 weeks

6 Apr 15 Jun 15 Aug 15 Oct 15 Dec 15 Feb 16 Apr 16 Jun 16 Aug 16 Oct 16 Dec 16 Feb 17 Apr 17 Jun 17 Aug 17 Oct 17 Dec 17 Feb 18 Apr 18 Long-term waiting The number of people waiting for longer than one year Currently, there are 3,101 people who have been waiting for over one year for their treatment to begin. Recently there has been a sizeable increase in the number of people waiting over one year. For example, the latest number is over double that reported just six months earlier in November ,500 Number of people waiting over 12 months 3,000 2,500 2,000 1,500 1, A sharp increase in the number of people waiting for longer than one year that began around December last year is clearly visible above. That change, and the relatively small number of people waiting over a year compared to the entire waiting list, make it difficult to produce a reliable forecast for future numbers of people who are likely to wait for over a year before their treatment begins. However, an examination of those who have waited over six and nine months reveals real cause for concern, suggesting that this rise heralds greater long-term waits in the future. A similar sharp upward turn in the number of people waiting over a year is also visible in the number of people waiting over six and nine months, as shown in the graphs below. Not only is this bad for those individuals, but it augurs badly for reducing the number of people waiting over 12 months. 6

7 Apr 15 Jun 15 Aug 15 Oct 15 Dec 15 Feb 16 Apr 16 Jun 16 Aug 16 Oct 16 Dec 16 Feb 17 Apr 17 Jun 17 Aug 17 Oct 17 Dec 17 Feb 18 Apr 18 Apr 15 Jun 15 Aug 15 Oct 15 Dec 15 Feb 16 Apr 16 Jun 16 Aug 16 Oct 16 Dec 16 Feb 17 Apr 17 Jun 17 Aug 17 Oct 17 Dec 17 Feb 18 Apr 18 Number of people waiting over 6 months 250, , , ,000 50,000 0 Number of people waiting over 9 months 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 Clearly, each person who has waited 12 months has first been waiting for longer than nine months. It follows that any sizeable growth in the number of people waiting longer than nine months will soon create pressure on the 12-month waiting time figure. These figures show that the number of people waiting for longer than nine months in May 2018 is 70% higher than 12 months ago, 180% higher than two years ago and 217% higher than three years ago. In turn, it follows 7

8 that the level of difficulty in reducing the number of people waiting over 12 months is going to become considerably harder. In turn, this reinforces how difficult it is likely to be to eliminate waiting times of longer than a year. In actual numbers, we can see that at no point in 2016 were there more than 20,000 people waiting beyond nine months. Another way of looking at this is that the maximum pool of people that must begin treatment within three months to avoid breaching the 12-month waiting time was 20,000. However, that pool of people has now grown to 36,000. The fact that the figure is also growing for six month+ waiters shows that the problem is backing up right through the waiting list. In turn, the recent sharp rise in people waiting over a year is not an isolated or one-off cohort of unusually long waiters. 8

9 Policy context and notes Waiting times This paper relies entirely on data published by NHS England 3 relating to the incomplete waiting pathway, i.e. those who are waiting for their treatment to begin. Current funding round This paper summarises how referral-to-treatment waiting time figures have changed over the past five years and estimates likely figures by March 2024, i.e. the end of the five-year funding period that was announced by the Prime Minister on 18 June It assumes that waiting times continue along their current trajectories. Changes in referral to treatment time policy In July 2015, NHS England changed its rules on waiting times to prioritise the incomplete standard over other waiting time measures such as those relating to admitted and non-admitted patients. This paper uses trajectories based on historic data over three and five years to forecast possible future figures. The three-year trajectory begins shortly after policy change was announced. Earlier this year, NHS England signalled a new focus on waiting times, i.e. to stabilise the number of people waiting for treatment on the RTT pathway. The planning guidance 5 sets out two objectives for referral to treatment times: 1. The number of patients on an incomplete pathway will be no higher in March 2019 than in March 2018 and, where possible, they [commissioners and providers] should aim for it to be reduced ; and 2. Numbers nationally of patients waiting more than 52 weeks for treatment should be halved by March 2019, and locally eliminated wherever possible. In March 2018, the total number of people on the incomplete RTT waiting list was 3,843,182 and the total number of people waiting over 52 weeks was 2,755. While it is reasonable to anticipate that there may be changes in waiting time performance as commissioners and providers adjust their plans to meet these new targets, we do not yet have enough data since these announcements to assess their impact. Linear extrapolations As noted above, this paper uses three-year and five-year historic trajectories to extrapolate likely future waiting times. While there is no fundamental rule that dictates linear growth rate the number of people waiting is essentially a product of the implementation of policy, resource and demographic pressures we do nevertheless see a remarkably linear pattern when the seasonal effects are removed as illustrated by the rolling 12-month average of people waiting (including estimates) below: NHS England: Refreshing NHS Plans for 2018/19, para 3.7, p. 10 9

10 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15 Dec-15 Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 Jun-17 Sep-17 Dec-17 Mar-18 Rolling 12 month av of all waiters inc estimates 4,300,000 4,100,000 3,900,000 3,700,000 3,500,000 3,300,000 3,100,000 2,900,000 2,700,000 2,500,000 Effect of non-reporting trusts NHS England has pointed out that the changing number of trusts that report their waiting times means we need to exercise caution when considering historic trends. For example, when Barts began to report its waiting times after a long hiatus for the period from April 2018, this added 88,333 patients to the national waiting list. Conversely, several organisations that reported waiting time data 12 months ago, no longer report their figures, so this considerably reduces the net effect of Barts resumption of reporting. It is therefore right to exercise caution, but even when these previously unreported patients are considered, the total number of people currently waiting is still at a record high. As noted above, it is difficult to estimate the future scale of missing data because it is due to a small and changing set of providers that for various reasons have not reported their waiting time figures. However, NHS England s estimates of people missing from the waiting data average at 174,207 over the past five years, and 202,503 over the past three years. Today s missing figure is therefore close to the mid-point of these two longer-term averages. It is also worth noting that there have been non-reporting trusts every month since September